01/01/2026 ASO Open Access Plus HDHPQ - HDHPQ 4500 Proclaim - 37302329 - V 33 - 10/20/25 05:26 PM ET 7 of 17 ©Cigna 2025 Benefit In-Network Out-of-Network Note: Services where plan deductible applies are noted with a caret (^). Plan deductible always applies before benefit copays/deductibles. Outpatient Dialysis Services Physician’s Services/Office Visit Covered same as Physician Services - Office Visit Not Covered Home Dialysis Note: Dialysis visits will not accumulate to Home Health Care maximum Covered same as plan's Home Health Care benefit Not Covered Outpatient Facility Services Covered same as plan's Outpatient Facility Services benefit Not Covered Outpatient Professional Services Covered same as plan’s Outpatient Professional Services benefit Not Covered Other Health Care Facilities/Services Home Health Care Plan pays 80% ^ Plan pays 50% ^  Annual Limit: 60 days (The limit is not applicable to mental health and substance use disorder conditions.)  16 hour maximum per day Note: Includes outpatient private duty nursing when approved as medically necessary Organ Transplants Inpatient Hospital Facility Services LifeSOURCE Transplant Network® facility Plan pays 100% ^ Not Applicable Other Facility Not Covered Not Covered Inpatient Professional Services LifeSOURCE Transplant Network® facility Plan pays 100% ^ Not Applicable Other Facility Not Covered Not Covered  Travel Maximum - Cigna LifeSOURCE Transplant Network® facility only: After the plan deductible is met, $10,000 maximum per Transplant Durable Medical Equipment  Annual Limit: Unlimited Plan pays 80% ^ Plan pays 50% ^